Provider Demographics
NPI:1871110841
Name:TAYLOR, MARK RICHARD (CATC 1)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:CATC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 S ESCONDIDO BLVD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6524
Mailing Address - Country:US
Mailing Address - Phone:760-504-3156
Mailing Address - Fax:
Practice Address - Street 1:1820 S ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6524
Practice Address - Country:US
Practice Address - Phone:760-504-3156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197217I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)